Provider Demographics
NPI:1104963784
Name:DACOSTA, MICHELLE NATALIE (DDS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NATALIE
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 N DR MARTIN LUTHER KING DR
Mailing Address - Street 2:MILWAUKEE HEALTH SERVICES INC
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2709
Mailing Address - Country:US
Mailing Address - Phone:414-372-8080
Mailing Address - Fax:414-760-3983
Practice Address - Street 1:2555 N DR MARTIN LUTHER KING DR
Practice Address - Street 2:MILWAUKEE HEALTH SERVICES INC
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2709
Practice Address - Country:US
Practice Address - Phone:414-372-8080
Practice Address - Fax:414-760-3983
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4727122300000X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health